HomeMy WebLinkAboutSeptic Pumping Slip - 55 SHERWOOD DRIVE 7/21/2016 Commonwealth of Massachusetts
City/Town of NORTH ANDOVE g MASSACHUSETTS
System u in g Recor
Y Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving aorttyyv ; °
r
A. Facility Information
Important: 11ltEti ^1 l,i, c;
When filling out 1. System Location:
forms onthe 1�V'K')OVEJ
computer, use 55 r--� xyu- A..f AI r f l/ii ki 6
only the tab key Address
to move your
cursor-do not �� 01_
use the return City/Town State Zip Code
key' 2. System Owner:
Name
Am
ierwn Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date t t 2. Quantity Pumped: I a
Gallons
3. Type of system: ❑ Cesspool(s) 19 Septic Tank ❑ Tight Tank
❑ Other(describe): —
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
00
6. System Pumped By:
�6t Ct
Name AA Vehicle License Number
W
Company --
7, Location where contents were disposed:
_ CAL. r'-, la-
Signature of Hauler Date
http://www.mass,gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
--
System Pumping Record
_ Form 4
DEP has provided this form for use by local Boards of Health. Th isystem Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer, use 's -S 1 r", A C°) x) 1�
only the tab key Address
to mov cursor e your
not City/Tow Ctlt State Zip Code
r
use the return e
key. 2. System Owner:
�
w ,�yy1
_. — -----.__-.._..----
Name
eran Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping -Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) E" Septic Tank ❑ Tight Tank
❑ Other(describe): — —
4, Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
4n --— — -- —
6. System Pumped By:
�y C) - --
Name Vehicle License Number
t
Company
7. Location where contents were disposed:
Signature o of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record •Page 1 of 1
For 4 __ System Pumping Record
Courrrrror enitt of ssachusetss
w ssactsrstts
, y��a�en_Pu iurecaa^
System Chvnw System ation
T i ncy ihoutine
Cesspool. Apo 'Yes Septic tank: w
M� `Yes
rata of Pumping: Quantity Pumped: —[,Jz>o Gallons
System Pumped By: WW Riw r EnViMM001, U.0 permit M
Contents transferred to:
Contents bisposed at:
bate: Pumper Signature:
Condition of System/Othea,Comments
i
bep Approved Form 12/07/95